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This is a personal web site, reflecting the opinions of its author. It is not a production of my employer, and it is unaffiliated with ANY hospital, medical center, medical practice or other physicians. Statements on this site do not represent the views or policies of anyone other than myself. The information on this site is provided for discussion purposes only, and are not medical recommendations. I offer no guarentee as to the accuracy of anything stated and the information here is at times, highly speculative and does not constitute advice to/not to diagnose or treat. Any personal medical issues the reader may have should be referred immediately to the reader's private physician and under no circumstances should anyone delay, change, or alter any medical treatment or planned treatment or diagnosis based on anything read on this site. Under no circumstances does any herein contained information represent a medical recommendation.

I was there in the early '90's when the market did what markets do, i.e., jumped ahead of Hillary (whose intentions were outlined early in the presidency) and anticipated drastic reimbursement reductions, or worse. This was exacerbated by the word out of Washington (and Jackson Hole -- lead by Uwe Rhinehardt) that "managed competition" effected through HMO's would be the predominant reimbursement strategy (read mandated). If you look back you will see that HMO enrollment expanded dramatically, and private insurers began cycling their prices higher and stratifying their policies to make HMO-like options the most appealing financially. This phenomenon is verified by the meteoric rise in the market capitalizations of HMO’s during this period. Once begun, this process has continued, as it would, until its maximum economic benefit began to be eroded by competition and negative market and provider/patient feedback. Notice there are select markets allowed to operate openly, in some ways, within the current health care system; but, each market has its own set of rules which is one reason why the health care market, as a whole, is so inefficient.

I strongly object to the unfair, contextually predatory characterization of me as having ill will towards “freeloaders” (foreigners, illegal aliens, migrant workers et al) of which I am accused. Here is what I wrote in my CodeBlueBlog concerning the ER waiting room:

If you walk through the waiting room, where patients sit for 5 and 6 hours to see a doctor for these mundane ailments, you’ll see a population predominantly composed of the young, the poor, immigrants, illegal aliens, migrant workers, and a smattering of the middle class. Although this population is disparate, it has a common bond drawing it the ER at all hours, for any physical complaint: no health care insurance.

My adumbration of the typical emergency room population was based on two data sets. First, the CBO report of 1/24/2004 that characterizes the uninsured population as: 39% under the age of 24; 51% as other than white, non-Hispanic; 91% without a college degree; and, by the way, 86% with health status ranging from good to excellent.

Second, my own 24/7/365 experience and observations of over 15 years servicing a community hospital ER that logs 100,000 visits a year. My assessment that migrant workers and illegal aliens are also heavily weighted in the ER population is certainly skewed by my geographical location in South Florida; however, the CBO and all other federal reporting groups on health care admit freely that they have no way to accurately gauge the number of these visits themselves, due to the vagaries of locating and studying this transient and sometimes elusive population.

One of my Blog objectives is to illustrate where health care dollars go. The Emergency Medical Treatment and Labor Act (EMTLA) of 1986 that obligates emergency rooms to assess and treat every person who walks through the doors is an example of the unanticipated consequences principle, and, without passing judgment on the populations affected, it needs to be addressed in any serious discussion of health care spending.

In my practice I, as with most other physicians I know, have yearly written off 40% of anticipated collections (without a tax deduction) for those who cannot – for whatever reason – afford the bill. This will surely evoke the perfunctory snide replies about “rich doctors,” but it is a fact, and it represents only a part of the countless hours every good physician I know spends in labor, efforts, and liability risk taking care of all comers.

Responding ahead to those who will snipe, let me say that if you look at the network of federal and state regulations governing physicians and the manner of reimbursement (fixed and regulated basically by the federal government’s Medicare scale), we are de facto public utilities. With that in mind, try asking Adephia or ConEd to write off the portion of your bill you cannot afford to pay. You’ll soon be using a flashlight to watch history unfold through your living room window.

Comments

You are not going to be able to rationally cope with the problems of the health care system until you come to grips with your own extraordinary prejudices. The largest and most obvious is your attachment to the term "reimbursement". Reimburse means to receive funds to replace what you have spent. Doctors are to reimbursed, they are PAID. The fact that you and most other doctors insist on a euphemism to obscure the fact that they are being paid is symptomatic of the rampant narcissism that leads to blaming everyone but themselves for the health care crisis. Your complaint about writing off ER fees is an artifact of your devotion to the holy principle of fee-for-service "reimbursement". We doctors who work on salary don't have this conniption.

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